1st Child's Name
Last First Middle
Sex MaleFemale    Birth Date(Month/Day/Year)

2nd Child's Name
Last First Middle
Sex MaleFemale    Birth Date(Month/Day/Year)

3rd Child's Name
Last First Middle
Sex MaleFemale    Birth Date(Month/Day/Year)

Program #1 Fall 2011 Program #2 Spring 2012 Faculty/Staff

Days of Week:

Parent's Name

Home Address
Street/Box#
City State Zip

Are you enrolled in classes at CSI? Yes No
Number of Credits    Major

Marital Status: Married Widowed Divorced Separated Single

Who will be responsible for Child Care costs?

Are you being aided by any of the following programs?
Pell Grant
ICCP
WIA
Vocational Rehabilitation
H&W Tafi Benefits
Food Stamps
Medicaid
Others

Ethnic Background: (Child)
White
Hispanic or Latino
American Indian & Alaskin Native
Black
Asian
Native Hawaiian or other Pacific Islander
Other

Language spoken at home

Special Needs: (Child)
Does your child have any physical limitations or special needs?    Yes    No
If yes, please explain

IN ACCORDANCE WITH FEDERAL LAW AND U.S. DEPARTMENT OF AGRICULTURE POLICY, THIS INSTITUTION IS PROHIBITED FROM DISCRIMINATING AGAINST ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, SEX, AGE, OR DISABLILITY.